Despite comprising over 70% of the global healthcare workforce, women remain significantly underrepresented in healthcare leadership. This imbalance has implications for care quality, as leadership diversity is increasingly recognised as a determinant of care quality, equitable outcomes, and health system performance. Structural barriers persist across academic medicine, health services, and professional organisations, limiting career progression and leadership opportunities for women. Existing efforts have largely prioritised individual-level interventions, with limited attention to the systems- and organisational-level determinants that influence adoption, implementation, and sustainability of gender equity initiatives. Coordinated action is needed to address gender inequality through sustainable, evidence-informed systems change. This protocol outlines the Organisational Change Management workstream within the Australian Advancing Women in Healthcare Leadership initiative, a nationally implemented, multi-sector partnership. Using a mixed-methods, co-produced implementation research approach, the workstream will implement and evaluate multi-level interventions and associated implementation strategies across system and organisational levels. Guided by the Consolidated Framework for Implementation Research, the Learning Health System framework, and the Reach, Effectiveness, Adoption, Implementation and Maintenance evaluation model, stakeholders are engaged across outer (policy, regulation, funding) and inner (organisational culture, leadership structures) settings. Data collection includes administrative datasets and policy documents, semi-structured interviews, and surveys. Qualitative data will be analysed thematically and quantitative data analysed descriptively. Findings will be triangulated to inform the selection, tailoring, and evaluation of implementation strategies and a codesigned implementation toolkit, supported by iterative learning cycles. This protocol describes a national initiative applying a systems- and organisational-level, co-produced approach to advancing gender equality in healthcare leadership, engaging health services, professional colleges and associations, government, and women in the workforce. By leveraging implementation science and systems change methodologies, the initiative aims to support sustainable organisational transformation. The protocol provides a replicable framework for advancing gender equality in healthcare leadership and beyond and contributes to implementation science by demonstrating how multiple established frameworks can be integrated to operationalise large-scale, system-level organisational change in complex healthcare systems.
National autism guidance increasingly shapes diagnostic practices and service pathways, yet comparative research has focused primarily on clinical content and methodological quality rather than the governance structures through which guidance is produced. We argue that differences in autism guidance are influenced not only by clinical recommendations but also by governance structure, lived-experience participation, and implementation architecture. This study examines how autism guidance is commissioned, who participates in development, and how guideline processes are linked to implementation across six countries: Australia, England, Norway, Scotland, Sweden, and the United States. Using qualitative comparative document analysis, publicly available guideline documents and associated methodological materials were examined to assess each country's guideline authority, document function and scope, procedural transparency, lived-experience participation, implementation linkages, and relationship to broader national autism strategy. Participation was categorized along a spectrum from consultation to representation to co-production. The analysis reveals substantial cross-national variation in how authority, participation, and implementation are structured within national autism guidance systems. Countries with centralized guideline authorities documented the most formalized mechanisms for incorporating lived-experience perspectives, while distributed or consultation-based models afforded less formal influence. Procedural transparency was generally high where centralized bodies existed but variable in distributed systems. Implementation linkages ranged from formal quality standards, indicators, and national strategy alignment to informal regional adoption. These governance differences are not fully captured by existing appraisal tools such as AGREE II. The findings provide a descriptive foundation for future research examining how governance arrangements influence autism guidance implementation, legitimacy, and impact.
This study presents the design, implementation, and experimental validation of an intelligent lighting control system based on artificial neural networks. The proposed system optimizes energy consumption while maintaining the required illuminance levels by adaptively adjusting artificial lighting in response to daylight variations and occupancy conditions. The control framework employs a feedforward neural network trained offline and deployed on an embedded lighting control unit. Rather than introducing a new neural network architecture, the work focuses on the embedded deployment and long‑term field operation of an ANN‑based controller in a real office environment. Experimental validation in a real‑world intelligent building demonstrated consistent energy savings of 7.4-12.5% during continuous operation and 8.5% under occupancy‑driven conditions while maintaining the required illuminance levels. The ANN model achieved high predictive accuracy (R² = 0.91) and stable performance under dynamic lighting scenarios. The implemented control algorithm ensured smooth dimming transitions and reduced abrupt illuminance fluctuations typically associated with conventional switching systems. The architecture enables real‑time operation on low‑cost hardware without high‑performance computing resources, making it suitable for retrofit applications. Overall, the findings confirm that ANN‑based adaptive lighting control provides a practical, scalable, and energy‑efficient solution for modern intelligent building automation and provide a basis for further validation across different building types and climatic conditions.
Accurate surgical case duration estimation (CDE) is critical for operating room efficiency, staffing, resource allocation, and patient safety. Traditional approaches-historical case averages, surgeon estimates, and variable use of electronic scheduling tools-frequently produce substantial under- or overestimation, leading to workflow disruption, overtime, and reduced access. This study developed and evaluated a machine learning (ML)-based CDE model and conducted a parallel human-factor analysis to identify contributors to scheduling variability at a high-volume tertiary cancer center. The authors curated 40,656 surgical cases across 22 service lines (2016-2024) and trained a gradient-boosted tree model (termed "ORchestra") using patient-, procedure-, and surgeon-specific features. Model performance was compared with existing scheduling practices, including originally scheduled duration, historical averages, and Epic's CDE tool under both user-adjusted and vendor-recommended configurations. Evaluation metrics included mean absolute error (MAE magnitude), mean signed error (MSE bias), and the proportion of cases scheduled within ± 30 min of actual duration (f30min) or within ± 10% of actual duration (f10%). Human-factor investigations assessed variation in scheduling behavior, definitions of case duration, and choice of software parameters. A silent-trial deployment examined real-world feasibility. Baseline scheduling practices demonstrated substantial systematic underscheduling bias (MSE = -31 min), wide variability across service lines, and low accuracy: overall MAE = 35.3 min, f30min = 0.52, and f10% = 0.09. Standardizing workflow elements-specifically, consistent inclusion of prep/wrap time and use of vendor-recommended Epic settings-substantially improved performance (MAE = 20.1 min, f30min = 0.81, and f10% = 0.37). The ORchestra ML model further reduced error (MAE = 19.8 min), eliminated systematic bias (+1.2 min), and decreased overscheduling outliers, with the largest gains observed in high-variability services. Notably, workflow standardization alone approached ML-level accuracy for many procedures, highlighting human-factor variability as a dominant source of error. ML-based CDE improves predictive accuracy and reduces disruptive scheduling outliers; however, real-world performance depends equally on standardized workflows, consistent software configuration, and unified operational definitions. This study demonstrates that successful deployment requires not only technical optimization but also organizational alignment, governance, and disciplined practice change. Integrating predictive tools into perioperative operations provides measurable benefit but must be paired with structured workflow redesign to ensure reliability, safety, and sustainable impact.
Urine drug screening (UDS) has become an increasingly prominent component of opioid stewardship in palliative care, driven by guideline recommendations, state, and institutional requirements. Despite this adoption, the evidence base supporting routine UDS in palliative populations has not been subjected to rigorous critical scrutiny. To evaluate the evidentiary foundation for routine UDS in palliative care and cancer pain populations, examining safety benefit, cost burden, ethical implications, guideline consistency, documented harms, and the risk of racially disparate application. Narrative review and critical analysis conducted in accordance with the SANRA framework. PubMed/MEDLINE was searched through May 2025 using structured search terms across three domains: UDT terminology, cancer/palliative care, and opioid therapy. Clinical practice guidelines (NCCN, ASCO, CDC) were reviewed systematically. Studies were included if they addressed UDT utilization, outcomes, or policy in adult patients with cancer or receiving palliative care on opioid therapy. No published study demonstrates that routine UDS in palliative or cancer pain populations improves patient safety outcomes, including overdose prevention, reduction in diversion, improvement in pain control, or survival. Aberrancy rates reported across studies range from 15-54% in palliative cohorts but represent surveillance findings, not safety endpoints. UDS rarely changes opioid management, and there are documented risks of financial toxicity, patient stigmatization, inappropriate care termination, and racially disparate application. Self-report likelihood ratio analysis demonstrates that UDS adds meaningful diagnostic information only when patients deny use - the scenario most ethically charged within a therapeutic relationship. Major guidelines recommend UDS while acknowledging that the evidence is at the lowest tier and that the practice can cause patient harm. Routine UDS in palliative care lacks demonstrated benefit and carries documented harm. Guideline bodies, policymakers, institutional leaders, and clinicians should restrict recommendations to clinically individualized situations pending prospective evidence of patient safety benefit. Future research requirements and an equity-informed framework for selective, indicated screening are proposed.
Some people experience side-effects from medicines which can lead to negative patient outcomes and increased NHS costs. Pharmacogenetic-guided prescribing supports the safety and effectiveness of medicines. The Pharmacogenetics Roll Out - Gauging Response to Service (PROGRESS) study is assessing the viability and utility of pharmacogenetic-guided prescribing in general practice. We conducted a parallel process evaluation to explore the barriers and enablers to implementing pharmacogenetic-guided prescribing in general practice, from a clinician perspective. Twenty-nine online semi-structured interviews were conducted with 30 general practice staff across 20 sites in England implementing the PROGRESS study. We used a modified framework approach to analyse the data, informed by the Consolidated Framework for Implementation Research and Normalisation Process Theory. Clinicians saw value in offering pharmacogenetic-guided prescribing in general practice, but limited testing to where they perceived it provided greatest benefit. There was limited evidence of practices planning for implementation beyond setting up the PROGRESS study. Sites tailored delivery of pharmacogenetics to their local practice context, which acted as an enabler to implementation. Delivering pharmacogenetic-guided prescribing within the confines of a research study and clinicians' workload acted as barriers to implementation. General practice staff understood the value and purpose of pharmacogenetic-guided prescribing, but there was little evidence of wider practice involvement beyond raising awareness among staff. PROGRESS involvement was viewed as more as proof of concept for research purposes, rather than normalising pharmacogenetics into routine practice.
Patient and public involvement (PPI) is well established in high-income countries (HICs). However, evidence on the existence of structured PPI programmes, including their training, implementation, coordination and assessment in low- and middle-income countries (LMICs) is sparse. Understanding how PPI is developed and supported in these settings is essential for strengthening equity, relevance, and accountability in global health research. We aimed to map existing evidence on the development, implementation, and evaluation of structured PPI programmes in LMIC health research and to identify gaps to inform future programme development. We conducted a scoping review guided by Joanna Briggs Institute methodology and reported the review using PRISM-ScR. We searched four databases; PubMed, Scopus, Web of Science, and CINAHL, for studies published between 2013 and 2023, and updated the search to May 2025. Studies were included if they described a structured PPI programme embedded within health research in LMICs. Data extraction focused on programme development, training, implementation, evaluation, and reporting using GRIPP2-SF. Data from excluded studies were synthesised to characterise broader involvement practices. Among the 13,875 studies retrieved, 483 were considered for full-text screening, of which only 68 were LMIC-based. Only one study, the SENSE-Cog Asia dementia programme, satisfied the inclusion criteria. This multisite initiative demonstrated that structured PPI is feasible in LMICs when supported by cultural adaptation, PPI coordinator roles, and tailored training for contributors and researchers. Most LMIC full-text articles that were excluded described community engagement, consultation, or participatory methods rather than a structured PPI programme. Common limitations included hierarchical decision-making cultures, limited awareness of PPI, literacy barriers, digital exclusion, and absent reimbursement or institutional systems to support sustained involvement. Structured PPI programmes are lacking in LMIC health research. Although engagement activities are active and diverse, they often lack the infrastructure required for sustained partnership-based involvement. We propose an LMIC PPI Programme Development Framework comprising five essential components: foundational training, programme infrastructure, culturally grounded development, involvement across the research cycle, and monitoring and evaluation. Strengthening PPI in LMICs will require investment, cultural adaptation, and systems-level support to advance more equitable global health research.
India experiences a wide mental health (MH) treatment gap, with around 0.73 psychiatrists per 100,000 people, and a massive unmet need for common MH disorders. Task shifting and sharing (TS/S), which is moving tasks from specialists to less-specialised providers, offers a solution but lacks systematic implementation guidance. Unlike more procedural clinical tasks, MH care can involve multiple entry points, varied task types, and contexts where, often, trust outweighs credentials. This paper describes TS/S models in Indian MH space, identifying implementation lessons. We undertook a qualitative assessment, using interviews, focus groups, and observations, studying four organisations (cases): with models of CHW-led screening and rehabilitation across 700 villages in rural Gujarat, multi-level community teams operating 80 clinics in coastal Kerala, corporate peer MH first aiders serving 200,000 + employees, and a planned security force nurse counsellor programme. Data were analysed through SHIFT-SHARE v1.0, a new six-stage guiding framework for TS/S implementation, complemented by alignment measures that we developed for cross-case comparison. Organisations developed novel approaches like deconstructing cognitive behavioural therapy (CBT) into shiftable components, engaging traditional healers as collaborative partners, and cross-subsidisation models for sustainability. However, monitoring and evaluation emerged as the weakest link across cases, and funding structures often failed to recognise clinical services, medication, and supervision as important components of TS/S. MH TS/S differs from procedural task transfer: success needs philosophical alignment among providers, community-suitable capacity building, and outcome measures looking at recovery beyond symptoms. Effective MH TS/S means redesigning services around trust and accessibility instead of delegating professional tasks downward.
Underserved communities face significant barriers to healthcare access, often resulting in reliance on emergency departments (EDs) for non-emergent conditions. Federally Qualified Health Centers (FQHCs) play a key role in addressing these disparities, though many lack integrated urgent care services tailored to the needs of specific populations. This case study describes the implementation of an emergency medicine-directed urgent care department within an FQHC serving a predominantly Ultra-Orthodox Hasidic Jewish community in Kiryas Joel, New York. This report is intended as an implementation-focused description of how urgent care services can be integrated alongside primary care within an FQHC, rather than as a causal evaluation of ED use, clinical outcomes, or primary care utilization. A descriptive analysis of de-identified patient encounter data from 2020 to 2025 was conducted to characterize patient volume and utilization patterns. From 2020 to 2025, patient volume increased from 1,215 to 13,636 encounters, representing a 1022.3% increase. Pediatric patients accounted for 65.1% of visits, comprising the majority of encounters. The department provides extended hours, holiday accessibility, and integrated referral pathways, supporting high utilization in a community with significant cultural and linguistic barriers. This case study suggests that an emergency medicine-directed urgent care model can be successfully implemented within an FQHC and achieve high utilization in an underserved population. While causal impacts on emergency department utilization, primary care utilization, continuity of care, and clinical outcomes were not evaluated, this model offers a practical framework for health centers seeking to expand same-day urgent care access within an integrated FQHC setting.
Dissemination science lacks shared language for specifying what dissemination strategies are designed to achieve. Without clearly defined outcomes, researchers cannot design studies that explain why dissemination strategies succeed or fail, compare findings, or build cumulative evidence about how dissemination works. We drew on dissemination scholarship, communication and behavior theory, innovation diffusion, public policy, and organizational readiness frameworks, and two decades of applied experience within a national HIV research network, to identify and iteratively refine a set of dissemination outcomes. We propose a taxonomy of eight dissemination outcomes: Exposure, Comprehension, Credibility, Salience, Perceived Fit, Leadership Endorsement, Action Readiness, and Decision to Implement. We distinguish these from dissemination mechanisms and from implementation outcomes, locating the boundary between dissemination and implementation at the decision to implement. We illustrate the taxonomy using three studies from the Adolescent Medicine Trials Network for HIV Interventions and offer it not as a prescriptive framework but as a conceptual starting point. We hope this shared language supports clearer study design and helps build cumulative evidence about how dissemination works.
In 2013, WHO partnered with Ministries of Health and development partners in nine countries in Asia and the Pacific to develop, test and scale-up of Early Essential Newborn Care (EENC), a package of simple evidence-based interventions shown to prevent or treat the most important causes of newborn morbidity and mortality, delivered around birth or in the early newborn period. This effort became the largest regional collaboration to improve the quality of newborn care globally. This article discusses the key achievements and progress in the introduction and scale-up of EENC over the past decade, as well as the remaining challenges and future directions. Policy and programme documents, cross-sectional facility assessments and study data show that EENC was widely adopted across nine countries between 2013 and 2023 using a coaching and data-based approach, with sustained and vastly improved quality of care for all newborns including those born preterm, low birth weight and by caesarean section. Implementation replaced ineffective training-based approaches with on-the-job clinical coaching tailored to routine environments. Multidisciplinary hospital teams drove national scale-up and systems improvements by identifying what their facilities and those in their catchment population needed to support practice change. The periodic collection and immediate use of practice data for tracking progress and making programme decisions represented a significant change in how public health programme implementation and scale-up was conducted in the region.
Medical genetics currently operates through a fragmented diagnostic cascade built around short-read sequencing technologies that carry well-documented blind spots, including regions of high sequence homology, tandem repeats and segmental duplications, as well as large or complex structural variants, invisible base modifications and a lack of variant phasing. We propose that long-read genome sequencing should be considered as one pillar of a broader technological convergence encompassing diploid genome assembly, pangenome references and artificial intelligence-driven variant interpretation, termed near-perfect genome sequencing (NPGS). We further propose a Bayesian framework in which genomic completeness itself constitutes interpretive evidence for variant classification. This principle has direct implications for the interpretation of variants of uncertain significance in clinical practice. We highlight the potential of NPGS across postnatal, prenatal and oncological settings and outline a staged implementation roadmap toward the one-test paradigm. We also address real-world implementation challenges, including cost, computational demand, equity and ethical considerations.
Alcohol is a leading global risk factor for more than 200 diseases, premature death and disability. We aimed to update the Alcohol Preparedness Index (API) to map global and regional policy trends between 2010 and 2019. We compiled policy data from 141 countries from the WHO Global Information System on Alcohol and Health and scored five domains: national policy frameworks; production, pricing, and taxation; marketing and availability; drink-driving countermeasures; and monitoring and surveillance. The primary endpoint was the percentage change in API between 2010 and 2019. We summarized trends by region and explored potential variables that explain these trends with an adjusted regression model. By 2019, less than 25% of countries had a strong national alcohol plan (defined as a written national policy accompanied by a formal action plan for its implementation), while 40% had none. Production, pricing, and taxation showed the clearest increase (27% in 2010 and 78% in 2019). Monitoring and surveillance reached strong levels at 47.5%. The median API rose from 57.0 [39.0-82.0] in 2010 to 74.8 [58.3-83.5] in 2016, remaining above baseline in 2019 at 67.8 [51.2-83.8]. Larger population size was a negative correlation of API change (β=-19.1, p<0.05). Human Development Index and alcohol per capita consumption were not significantly associated with API change. From 2010 to 2019, preparedness on alcohol policy increased globally, though progress remained uneven across domains and regions. These findings highlight persistent policy gaps and support the prioritization of evidence-based interventions aligned with the SAFER framework. Future efforts should focus on translating policy presence into implementation, with particular attention to domains most strongly linked to alcohol-associated liver disease outcomes. Despite the well-established harms of alcohol, global trends in alcohol policy preparedness remain poorly characterized. Using the validated Alcohol Preparedness Index across 141 countries, we demonstrate meaningful but uneven global progress between 2010 and 2019, with gains concentrated in taxation and monitoring domains while national planning and marketing controls lagged, particularly in low-income regions. These findings are directly relevant to policymakers and public health authorities, as stronger alcohol policy environments have previously been linked to lower rates of alcohol-associated liver disease, hepatocellular carcinoma, and cardiovascular mortality. Within the limitations of an ecological study design, this work provides a practical roadmap for identifying policy gaps and prioritizing interventions aligned with the WHO SAFER framework to reduce the global burden of alcohol-related disease.
Tuberculosis (TB) is an ongoing international health issue, which is particularly common among the communities who live in poverty, marginalization and social disparity. Understanding that purely biomedical strategies are unable to reach those settings, national TB initiatives are turning to community engagement strategies to expand reach, enhance the early detection process, encourage treatment compliance, and aid in eliminating stigma. This paper critically evaluates the aspects on ethics which determine the involvement of communities in the TB prevention programs and argues that community involvement is not always good, unless the design and implementation of the activities based on the principles of ethics are applied to protect the rights, dignity and agency of the suffering populations. Creating a conceptual frameworks and model analysis under different circumstances, including informal settlements within cities, migrant worker locations and distant tribal locations, the research outlines significant ethical prospects and threats, which are incorporated in community engagement. Results show that community-based interventions usually lead to substantial screening, adherence, and trust gains though they also show persisting dilemma concerning breach of confidentiality, fuzzy consent, unequal loss of power, and risk transfer onto volunteers and peer supporters. The graphical analysis and an example of the field further promote the fact that there are differences in ethical issues in the different social contexts, which require adaptive and participatory governance rather than standardized solutions. The paper is summarized as having made the case that ethically informed community engagement is not just a moral requirement but also an empirical necessity of sustainable TB control and requires continuing ethical reflexivity, improved safeguards and policy frameworks that should foster partners in the community as co-producing health and not supporting Labour. The introduction of ethics into the design, implementation, and monitoring of TB programs will enable the public health agencies to take a step towards more equitable, legitimate, and community-owned avenues to TB elimination.
Pasifika, migrant populations from Oceania in Australia, experience high prevalence of diabetes and obesity. Lifestyle interventions targeted at weight loss have shown beneficial effects in reducing the risk of type 2 diabetes (T2DM). To identify a weight loss component for a broader lifestyle clinical trial a study testing feasibility, acceptability and sustainability of a culturally tailored lifestyle intervention was delivered in Sydney, Australia. The study is a before-and-after single-arm feasibility study informed by a combined socio-ecological model and the newly developed Cultural and Sustainability Assessment of Intervention (CSAI) framework. Participants were adults from a Samoan church community who volunteered and provided consent. The intervention was a weight loss challenge delivered over 12-week sessions using 12 lifestyle messages targeting physical activity and healthy eating habits with an additional message on planning and tracking goals. Implementation was delivered by a peer-support and volunteer structure. The primary outcome was change in weight (kg) with secondary outcomes of change in physical activity and dietary behaviour and HbA1c, amongst others. Lead by the community, the intervention was repeated at 12-months. There was sustained engagement in the intervention, with low attrition rates (5.2%) and low resource requirements. At baseline, n = 36/51 (71%); 34 completed pre-post measurements at 12 weeks. Significant reductions were found in primary outcomes of reduced (median difference [IQR]) weight = -3.4[6.7]kg, p = 0.01; BMI = -1.1[2.3] kg/m2, p = 0.002; and body fat (BF) = -3.5[6.9]%, p = 0.03. Secondary outcome improvements included increased physical activity (≥ 3 days vigorous exercise weekly) (χ2 = 3.61, p < 0.001), and reduced sitting times (χ2 = 7.69, p = 0.003). Those attending ≥ 8 sessions demonstrated greater overall changes in clinical outcomes. At 12-months, a repeat of the intervention resulted in mean 4.8 kg (SD ± 6.05), p = 0.002 weight loss. Community reported acceptance of the tailored intervention as culturally relevant with the support structure as crucial for implementation. Results of this single-armed study indicate feasibility of the 12-week competition-based WLC to elicit weight loss in a minority population, such as Pasifika. Community response attested to acceptance and viability of the support structure. Opportunities exist to revise materials and use the CSAI to design culturally appropriate and tailored interventions to better engage Pasifika and minority populations.
To calculate the cost per patient of ophthalmological care for patients referred from primary care under a telematic model (Quixote® project), compared with conventional face-to-face care at the Hospital Universitario de Jerez, within the Jerez, Sierra de Cádiz, and Northwest Coast Health Area (Spain). Comparative analysis of direct costs of telematic ophthalmological care versus the traditional face-to-face model, alongside a retrospective observational evaluation of efficiency after implementation of the Quixote® project. Outcomes included accessibility (mean waiting time in days for ophthalmological care, cumulative primary care waiting list) and patient satisfaction. The direct cost of complete care using the telematic model was €22.47 per patient compared with €32.5 per patient for the face-to-face model. Among 4,288 patients evaluated in the Quixote® project at HUJ, 2,659 patients (62%) required referral for face-to-face hospital assessment, while 1,629 (37.9%) were discharged. The mean waiting time for patients referred from primary care decreased from 89 days to 39 days (-56.8%; 95%CI, 53.8%-58.5%; P <  .0001). The cumulative waiting list decreased from 4,606 to 1,684 patients (-64%; 95%CI, 61.7%-66.3%; P <  .0001). Implementation of the Quixote® tele-ophthalmology programme is a cost-efficient strategy for delivering ophthalmological care. It improves patient throughput from primary care, reduces waiting lists, optimizes hospital resources, and facilitates early detection of relevant diseases.
Mentorship and sponsorship play pivotal roles in career development, yet disparities in access to these opportunities persist among medical trainees. This report describes a structured alumni engagement programme for pulmonary, critical care and sleep medicine fellows, aimed at fostering mentorship, professional development and equitable career opportunities. Conducted within a university-based fellowship programme, the intervention comprised seven themed virtual sessions featuring alumni from diverse career trajectories, including academia, industry and private practice. Thematic analysis of session transcripts identified ten key themes across four domains: career development, personal fulfilment, professional relationships and adaptability. Postsession feedback indicated high participant satisfaction, with 53% of fellows reporting subsequent mentorship or career opportunities with alumni. Limitations include the small sample size, short follow-up period and lack of full characterisation of baseline features. This initiative highlights the scalability and potential impact of alumni engagement on career development, emphasising the importance of mentorship and sponsorship. Broader implementation could enhance networking opportunities across medical disciplines, addressing long-standing disparities in access to professional growth resources. Future studies should focus on longitudinal outcomes to assess the influence of such programmes on trainees' career trajectories. This innovative model offers a replicable framework to strengthen professional networks and support leadership development among trainees.
This study aims to assess how Primary Care Physicians (PCPs) in Portugal currently approach opportunistic prostate cancer (PCa) screening using Prostate Specific Antigen (PSA) testing, and to explore variations in both screening and shared decision-making (SDM) practices. An electronic survey was distributed in 25 Health Centers in Portugal between June 2024 and June 2025. The questionnaire assessed respondents' demographic and practice characteristics, PSA screening criteria and frequency, implementation of SDM, knowledge and use of decision aids, and urology referral patterns. Associations between provider characteristics and screening practices were analyzed using Pearson chi-square or Fisher's exact tests. A total of 107 PCPs participated in the study, the majority being female (81.3%) and under 40 years old (72.9%). Those with less than 10 years of experience were more likely to adjust PSA testing frequency based on initial PSA levels, especially for men aged 50-59 (p = 0.015) and 60-74 (p = 0.004). Routine screening of younger men or those over 75 was uncommon unless specific clinical factors were present. National guidelines were the primary influence on clinical practice (75.7%), particularly among less experienced physicians (p = 0.027). In terms of SDM, most PCPs explained PSA testing (80.4%), but only 64.5% consistently discussed its benefits and risks or explored patient preferences, with those in the South region of Portugal more likely to do so (p = 0.012 and p = 0.002 respectively) than those in the North/Centre. Decision aid awareness and use were low; only 6.5% reported having used them, while 72% were unfamiliar with these tools. Most referrals to urology were triggered by abnormal transrectal ultrasound findings (72%) rather than elevated PSA alone (16.8%). Full support for population-based PCa screening was limited (12.2%), and male physicians were significantly more likely to endorse it (p = 0.007). PCa screening practices among Portuguese PCPs remain a complex area of primary care, characterized by variability in clinical approaches, inconsistent guideline adherence, and limited application of SDM. Despite general awareness, notable gaps persist in the use of decision aids and evidence-based referral criteria. These results highlight the need for clearer national guidance and greater support for individualized, patient-centered screening strategies. not applicable.
Radical prostatectomy (RP) practice has been transformed by active surveillance (AS) guidelines for low-risk prostate cancer and the 2014 ISUP Gleason reclassification. The aim of this study was to describe the temporal evolution of clinical and pathological characteristics of patients undergoing RP at two high-volume French centers over 18 years. We retrospectively analyzed 8,358 consecutive RPs performed between January 2007 and December 2025 at Hôpital Foch and Institut Montsouris (Paris). Patients were stratified by D'Amico risk classification across three periods (2007-2012, 2013-2018, 2019-2025). Low-risk patients declined from 4.5% to 0.6% (p<0.001); high-risk patients increased from 9.5% to 21.7% (p<0.001). Biopsy Gleason score ≤6 fell from 48.0% to 4.2% (p<0.001). Pathological stage ≥pT3 rose from 30.5% to 47.3% (p<0.001) and lymph node involvement (pN1) from 1.0% to 5.4% (p<0.001). Median age increased from 62.6 to 66.2 years (p<0.001). These shifts accelerated after 2012-2014, coinciding with major AFU guideline revisions and the ISUP reclassification. This large bicentric series demonstrates a profound and sustained shift in the risk profile of patients undergoing RP over 18 years, with near-disappearance of low-risk cases and growing proportions of high-risk and pathologically advanced disease, which may reflect successful guideline-concordant AS implementation.
A key underlying principle of causal inference is that of well-defined interventions. Although ultra-processed food (UPF) has been associated with a greater risk of type 2 diabetes (T2D), subtypes of UPFs may exert different strengths and directions of associations. The main objective of this study was to systematically evaluate the current literature on subtypes of UPFs and their associations with T2D and to contextualize these findings within the framework of sufficiently well-defined interventions for causal inference. We searched PubMed and Embase for relevant articles. Cohort studies of adult men and women without T2D were included. Two independent researchers screened the articles and evaluated risk of bias using the ROBINS-E tool. UPFs were categorized into eight subtypes. A post-hoc analysis of 52,201participants in the Danish Diet, Cancer and Health (DCH) cohort was performed to illustrate the implications of vaguely defined interventions. We formed a fictive food group (the terrible five) combining foods that have been associated with T2D: sugar sweetened beverages, processed meat, red meat, refined grains and vegetables, and investigated the associations with T2D. Out of 222 articles screened for eligibility, 6 cohort studies with 635,332 participants (average follow-up of 6-26.1 years) were included. Most studies on UPF ready-to-eat-dishes; meat-based products; and artificially and sugar-sweetened beverages were positively associated with T2D whereas UPF dairy products; and sweets, snacks and confectionaries were generally inversely associated with T2D, although with some variation. Overall risk of bias was considered moderate to high in all included studies. In the DCH cohort, a positive association between the "terrible five" and T2D was observed. Intake of vegetables was inversely associated with T2D. The systematic review showed different strengths and directions of associations on the risk of T2D across the different subtypes of UPFs. Aggregating these sources into a coarse food category such as UPF may therefore undermine the core principle of well-defined interventions and, as illustrated in our post-hoc analysis, can mask individual associations. This study illustrates potential unintended consequences of broad food categorizations such as UPFs and hamper implementation of UPF policies without further improvement of the definition or mechanistic understanding. The protocol was registered in PROSPERO (ID: CRD420251058458).